Wic Medical Referral Form For Infants ( Birth To 12 Months)

NEW YORK STATE DEPARTMENT OF HEALTH

WIC MEDICAL REFERRAL FORM FOR INFANTS

DIVISION OF NUTRITION

( BIRTH TO 12 MONTHS)

APPLICANT - INFANT: Please complete this section on your infant.

Infant’ s Last Name (Print): ______________________________

Infant’ s First Name: ___________________________________

Parent/Guardian’ s Name: _______________________________

Street: __________________________________Apt:_________

On WIC Before: £ Yes

£ No

Sex: £ M

£ F

City: ___________________________ Zip: _________________

Phone: (____) ______-______ Date of Birth: _____/____/_____

Language(s) Spoken: __________________________________

I authorize ____________________________(Health Care Provider) to release the information below to the WIC Program and I

authorize the WIC Program to release information about my infant to this health care provider for the purposes of coordinating his/her

health care. If I need to transfer to another WIC Program, I authorize the release of this information to the transferring WIC Program.

All information is considered confidential.

YOUR SIGNATURE: ________________________________

HEALTH CARE PROVIDER: Please complete this section - WIC eligibility will depend on this information.

BLOODWORK

ALL MEDICAL/HEALTH CONDITIONS NEED TO BE

must be no more than 90 days old on the date of

the WIC appointment: _______/________/________

VERIFIED BY A HEALTH CARE PROVIDER.

Blood work required for infants older than 6 months.

One blood test required:

Date Taken:

Please check all that apply:

OR

Hgb _________ grams/dL

Hct ________%

_____/_____/_____

£

Genetic/Congenital Disorders, Inborn Errors/Thyroid Disorders:

Blood Lead ____________mcg/dL (Optional)

_____/_____/_____

Specify___________________________________________________

£

Nutrient Deficiency Diseases/Anemia:

WEIGHT AND STATURE

must be less that 60 days old on the

date

Specify___________________________________________________

of the WIC appointment: _______/______/______

Date Taken:

£

Failure-To-Thrive

OR

Current Weight _______lb _____oz

_____kg

_____/_____/_ ___

£

£

Insulin Dependent Diabetes

Hypoglycemia

OR

Current Height/Lenght ________in

_____cm

_____/_____/_____

£

£

Essential/Chronic Hypertension

Asthma

£

Measurement Taken:

Recumbent (<2 yrs)

£

£ SGA (<10th Weight for Gestational Age)

Gastrointestinal Disorders: Specify _________________________

BIRTH HISTORY

£

£

Celiac Disease

Pyloric Stenosis

OR

Birth Weight _________lb _________oz

___________kg

£

Recent Major Surgery, Trauma or Burns within 6 months

OR

Birth Length _________in

_______cm Weeks Gestation ________

£

Infectious Diseases within 6 months: Specify ________________

IMMUNIZATION

Dates OR Attach copy of record:

£

Food Allergy (ies): Specify _______________________________

First

Second Third

Fourth

Fifth

£

Hep B

Other Chronic Medical/Health Conditions/Diseases:

DTP/DTaP

Specify _______________________________________________

Hib

£

Depression (Children)

Polio

£

Fetal Alcohol Syndrome

MMR

Var

£

Other: Specify _________________________________________

The NYS WIC Program encourages Breastfeeding for all infants.

£

£

£

£

Check appropriate box:

Breastfed

Milk-Based Formula

Soy-Based Formula

Other ________________

________________________________

_________________________

______________________________________________________

Signature of Health Care Provider (OR Stamp)

Provider ID #

Managed Care Plan Code

_______________________________________________________________

______________________________________________________

Provider’ s Name (Please Print)

Health Center/Hospital/HMO/Physician

Title ___________________________________________

Street __________________________________________________________

Date _____/______/______

Phone (____)______-_______

City __________________________________

Zip ____________________

Date Mailed/

Date Rec’ d

Send Completed Form To:

For WIC Use:

Clinton County WIC Program

Given

133 Margaret Street , Plattsburgh, NY 12901

Appt Date

WIC ID #

WIC is an equal opportunity program. Persons who believe they have been discriminated against because of race, color, national origin, sex, age, or disability, should write to the Secretary of Agriculture, USDA, Washington, DC, 20250. New York State also prohibits discrimination

based on race, color, national origin, sex, age and disability. In addition, New York State prohibits discrimination based on creed and marital status. Persons who believe they have been discriminated against based on the New York State Human Rights Law should call the Growing Up

Healthy Hotline at 1-800-522-5006.